Terms and Conditions of Insurance
I hereby state that I have no knowledge of any incident, pending claims, suits, or other ethics violations nor have any been filed against me in the past pertaining to my practice as a practitioner, that no certifications or licenses have been revoked, and that I have never been arrested for or been charged with any sexual violation. I understand that this application is subject to approval with no automatic inclusion in the program. My digital signature shall verify that I have completed this application accurately and honestly and that I agree to provide proof of training should I be asked to provide it in the event of a claim. I understand that I am responsible to verify that the coverage is appropriate to my training and professional activity, and that activities outside the scope of coverage of the policy are not covered. I understand that any false statement made on this application or subsequent renewals shall void this application and render my insurance coverage null and void. I understand that premium/fees paid by me are nonrefundable, nontransferable and will not be prorated. This application is for a policy which will expire 12 a.m. April 1 each year.